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psnet.ahrq.gov/issue/incidence-adverse-events-and-negligence-hospitalized-patients-results-harvard-medical
February 18, 2011 - Study
Classic
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.
Citation Text:
Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng…
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psnet.ahrq.gov/issue/medicare-payment-selected-adverse-events-building-business-case-investing-patient-safety
September 18, 2009 - Study
Medicare payment for selected adverse events: building the business case for investing in patient safety.
Citation Text:
Zhan C, Friedman B, Mosso A, et al. Medicare payment for selected adverse events: building the business case for investing in patient safety. Health Aff (Millw…
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psnet.ahrq.gov/issue/forum-100000-lives-campaign-scientific-and-policy-review-ihi-response
March 13, 2013 - Commentary
Classic
Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response].
Citation Text:
Wachter R, Pronovost P. The 100,000 Lives Campaign: A scientific and policy review. Jt Comm J Qual Patient Saf. 2006;32(11):621-7.
Copy Cit…
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psnet.ahrq.gov/node/61037/psn-pdf
January 01, 2021 - What safety events are reported for ambulatory care?
Analysis of incident reports from a patient safety
organization.
October 21, 2020
Sharma AE, Yang J, Del Rosario JB, et al. What safety events are reported for ambulatory care? Analysis
of incident reports from a patient safety organization. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/47559/psn-pdf
November 14, 2018 - Changes in prevalence of health care-associated
infections in U.S. hospitals.
November 14, 2018
Magill SS, O'Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care-Associated Infections in U.S.
Hospitals. N Engl J Med. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550.
https://psnet.ahrq.gov/issue/change…
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psnet.ahrq.gov/node/40405/psn-pdf
February 10, 2015 - The social cost of adverse medical events, and what we
can do about it.
February 10, 2015
Goodman JC, Villarreal P, Jones B. The social cost of adverse medical events, and what we can do about
it. Health Aff (Millwood). 2011;30(4):590-595. doi:10.1377/hlthaff.2010.1256.
https://psnet.ahrq.gov/issue/social-cost-adv…
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psnet.ahrq.gov/node/36291/psn-pdf
October 25, 2010 - Medicare payment for selected adverse events: building
the business case for investing in patient safety.
October 25, 2010
Zhan C, Friedman B, Mosso A, et al. Medicare payment for selected adverse events: building the business
case for investing in patient safety. Health Aff (Millwood). 2006;25(5):1386-93.
https:/…
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psnet.ahrq.gov/node/37974/psn-pdf
March 04, 2011 - The impact of medical errors on ninety-day costs and
outcomes: an examination of surgical patients.
March 4, 2011
Encinosa W, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination
of surgical patients. Health Serv Res. 2008;43(6):2067-85. doi:10.1111/j.1475-6773.2008.00882.x.
…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - units of transfused red blood cell units results in death due to acute
hemolytic reaction.17,18
When estimating
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - Because outpatient ambulatory health care delivery is a fragmented process, estimating medication errors
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psnet.ahrq.gov/taxonomy/term/3477
Failure Mode and Effect Analysis (FMEA)
A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an infusion pump or preparing an intravenous medicat…
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psnet.ahrq.gov/node/44560/psn-pdf
January 23, 2017 - What is the return on investment for implementation of a
crew resource management program at an academic
medical center?
January 23, 2017
Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a
Crew Resource Management Program at an Academic Medical Center? Am J Med…
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psnet.ahrq.gov/node/39852/psn-pdf
February 10, 2015 - National costs of the medical liability system.
February 10, 2015
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff
(Millwood). 2010;29(9):1569-1577. doi:10.1377/hlthaff.2009.0807.
https://psnet.ahrq.gov/issue/national-costs-medical-liability-system
The role of medi…
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psnet.ahrq.gov/node/44353/psn-pdf
November 03, 2015 - Evaluation of symptom checkers for self diagnosis and
triage: audit study.
November 3, 2015
Semigran HL, Linder JA, Gidengil C, et al. Evaluation of symptom checkers for self diagnosis and triage:
audit study. BMJ. 2015;351:h3480. doi:10.1136/bmj.h3480.
https://psnet.ahrq.gov/issue/evaluation-symptom-checkers-self…
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psnet.ahrq.gov/node/38983/psn-pdf
February 10, 2015 - Improving safety and eliminating redundant tests: cutting
costs in U.S. hospitals.
February 10, 2015
Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in
U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484. doi:10.1377/hlthaff.28.5.1475.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
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psnet.ahrq.gov/node/37831/psn-pdf
December 23, 2012 - Charges and lengths of stay attributable to adverse
patient-care events using pediatric-specific quality
indicators: a multicenter study of freestanding children's
hospitals.
December 23, 2012
Kronman MP, Hall M, Slonim A, et al. Charges and lengths of stay attributable to adverse patient-care
events using pediat…
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psnet.ahrq.gov/node/43928/psn-pdf
April 08, 2018 - Missed diagnoses of acute myocardial infarction in the
emergency department: variation by patient and facility
characteristics.
April 8, 2018
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency
department: variation by patient and facility characteristics. Diagnosis …
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psnet.ahrq.gov/periodic-issue/periodic-issue-333
March 31, 2022 - March 16, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - The national cost of adverse drug events resulting from
inappropriate medication-related alert overrides in the
United States.
September 5, 2018
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate
medication-related alert overrides in the United States. J Am M…